mm case two no Miss mortality case..pptx

Unexpected poorly done

1. Maternal mortality meeting 3/8/23

2. TM P3G4(3 alive), LNMP 7/9/22, EDD 15/6/23, EGA 39w DOA 15/6/23 DOD 24/6/23 REFFERAL FROM: RUWA CLINIC Booked at Ruwa clinic at 21/40, 4 ANC visits, HIV neg, RPR ND, USS done no record Dx G. HTN at 28/40 commenced on methyldopa 500mg po tds NB: Hx hypertension in all prior pregnancies

3. At clinic Presented at 3.15 with a hx of fitting about 10 times since 2300 3 day hx of headache and blurry vision O/E BP 134/94 P 100 depressed LOC ABD- HOF 39 long ceph FHNH with pinard VE-not documented MgSO4 4g in each buttock Catheterized Transfer to MNMH (ambulance contacted) 54mins later delivered LGI BWT 2750g in thick msl APGAR 9-10 EBL +/-120ml Left clinic at 4.35

4. At PGH Arrived at 5.30 (1hr) BP 234/117 P 89 depressed LOC Uterus not well contracted, VE expelled clots IMP: eclampsia and PPH PLAN Admit ELW Misoprostol 800mcg pr stat Ct mgso4 course Input-output Nifedipine 20mg po bd Hydralazine 12.5mg IM stat if bp >/= 160/110 Oxytocin 40iu /l infusion FBC, U&E, LFT, G&R

5. Seen at handover BP 164/102 P116 LOC V1 E4 M5 (10/15) swollen tongue Reduced urine output(<100ml in ?time, concentrated) Uterus well contracted, moderate pv loss Added oral and pressure point care Fit chart TED stockings

6. Results FBC WCC.25 HB.13 PLT.105 MCV.78 U&E Na144 K4.4 Ur4 Cr92.8 Cl107 eGFR75 LFT TP68.7 Alb 33.9 AST 826 ALT453 ALP234 GGT25 Tbil 75 Dbil27

7. Problems Depressed LOC Seizures Elevated blood pressures Acute kidney injury

8. DAY PROGRESS PLAN 1 BP 159/108 P125 Spo2 100% OFA LOC (V2 E3 M5=10/15) 10.32: matron concerned about patient’s depressed LOC and possible need for ICU admission contacted consultant on cover who advised to reach anasthetist . 11.16: seen by Anasthetics SHO Dexamethasone 8mg iv tds Informed senior No current need of ICU bed TX feeds 200ml 4hrly Physiotherapy R/V in 4hrs 2 01.44: added HCT 12.5mg po od 7:00: LOC M3 V2 E2=7/10, had secretions needing suctioning to breath 7.47: Ana r/v- ?Mg toxicity, 14.54 LOC E2 V2 M1 5/10 gluc 4.9 BP130/62 U&E Ur12.2 Cr141 K3.6 Na141. FBC WCC14.6 Hb11.5 MCV79 PLT 131 NO MPs admit ICU (no bed, another patient with LOC 5/15 in ELW being prioritized, mg levels, ct brain 3 14.56 Admitted into ICU- no intubation Ct scan brain in pvt - no bleed CT 4 LOC E4 V2 M4 10/15, paucity of mvt of left upper limb BP 163/92 Gluc 8.7-12.4 Temp 35.8-39.2 Neurosurgeons mild effacement of sulci and gyri in parietal and occipital regions with open basal cisterns, no intracranial bleeds or hydrocephalus Had episodes of secretions needing suctioning to relief Discharged to CCU- no bed so went to ELW CXR

9. Day 5 Seen by gyn reg Saturating 73% OFA LOC E4 M1 V1= 6/15 Noted U&E Na152 K4.1 Ur12.9 Cr 127 FBC WCC16.5 Hb10.3 PLT 219 MCV86.7 ½ N/S 42ml/hr Concern for aspiration pneumonia

10. Day 6 BP 160-170/80-111 LOC E4 V2 M3 9/10 Consult ana for readmission into icu Physician to review

11. Day 8 CCU bed now available Yet to be r/v by physicians 16.13 transferred to CCU Unfortunately day 9 at 1.30 patient certified dead

12. Delays 1: late booking, symptomatic for 3/7 prior to presentation, fitted 10 times before presentation 2: transport between clinic and hospital 3: no ct scan in gvt , no icu bed, rv by physicians, no mannitol or dexamethasone given, no documented physiotherapist involvement

13. Cause of death Eclampsia Group 2 ICD code O15.1

14. Avoidable/ Unavoidable Educate patients on early booking Standardize management across all healthcare facilities Improve availability of imaging and medication in public hospitals